Healthcare Provider Details

I. General information

NPI: 1609477280
Provider Name (Legal Business Name): MARLENE A ESPINOSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 N, IL 83
ROUND LAKE BEACH IL
60073
US

IV. Provider business mailing address

1812 HARRISON AVE
MUNDELEIN IL
60060-1062
US

V. Phone/Fax

Practice location:
  • Phone: 847-987-6007
  • Fax: 847-265-3423
Mailing address:
  • Phone: 847-987-6007
  • Fax: 847-265-3423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.287016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: